Starlight Care Seniors, LLC

Based on documentation review and interview, the manager failed to ensure that a plan was implemented for an ongoing quality management program that, at a minimum, included the frequency of submitting a documented report to the governing authority. The deficient practice posed a risk as a quality management program documents the necessary information required to effectively manage services provided. Findings include: 1. A review of the facility's policies and procedures revealed a policy titled "Quality Management Program Including Incident Reports" reviewed and signed by E1 in 2025. This policy stated, "In order to provide quality and safe services to the facility residents, the manager shall ensure that: 1. Facility personnel will document and evaluate incidents at the facility to ensure quality services are provided. 2. A copy of each filled out form regarding the incident, accident, emergency, unusual occurrence, or event that puts the resident in danger, including incidents regarding opioid-related adverse reactions or other negative outcomes a resident experiences, or opioid-related deaths, will be placed in the QOS Folder and the Quality of Service Monthly Recording Form. Information collected is to be used to accurately report and evaluate services provided to residents as per procedure below. 3. Facility may use a survey tool (Quality of Service Monthly Recording Form) to help in identifying and collecting information. Data and reports collected are used to identify a concern..." However, no documentation of any quality management program was available for review. 2. In an interview, E1 reported that the quality management program was implemented; however, it was unavailable to locate at the time of inspection. 3. In an exit interview, findings were discussed with E1, and no additional information was provided.

Based on documentation review and interview, the manager failed to ensure the quality management report required in R9-10-804(2) and the supporting documentation for the report was maintained for at least 12 months after the date the report was submitted to the governing authority. The deficient practice posed a risk as the Department was unable to determine substantial compliance during the inspection. Findings include: 1. R9-10-804.2.a-b states: A manager shall ensure that: 2. A documented report is submitted to the governing authority that includes: a. An identification of each concern about the delivery of services related to resident care, and b. Any change made or action taken as a result of the identification of a concern about the delivery of services related to resident care; and 2. A review of the facility's policies and procedures revealed a policy titled "Quality Management Program Including Incident Reports," reviewed and signed by E1 in 2025. This policy stated, "5. Documentation of all reports made in regards to the resident care will be submitted to the governing authority... The facility governing authority reviews and evaluates the effectiveness of the quality management program at least once every 12 months." 3. The Compliance Officer requested to review the facility's quality management report and supporting documentation for the report as required in subsection (2). However, a quality management report was not available for review. 4. In an interview, E1 reported that the quality management program was implemented; however, it was unavailable to locate at the time of inspection. 5. In an exit interview, the findings were reviewed with E1, and no additional information was provided.

Based on record review, observation and interview, the manager failed to ensure a resident medical record contained a medication order from a medical practitioner for each medication that was administered, for two of two residents sampled. The deficient practice posed a health and safety risk. Findings include: 1. A review of R1's medical record revealed a current written service plan that included personal care services and medication administration. 2. A review of R1's medical record revealed an August 2025 and September 2025 electronic medication administration record (eMAR). The eMAR included the following medication, which was administered to R1 from August 2025 to present; -Diclofenac 1% Gel – Otc Apply 2 Grams Topically To Affected Area(S) 4 Times Daily – 8:00 Am, 12:00 Pm, 5:00 Pm, 8:00 Pm -Nitrofurantoin Mono-Mcr 100 Mg Take 1 Capsule By Mouth Twice Daily – 8:00 Am, 5:00 Pm -Tamsulosin Hcl 0.4 Mg Capsule Take 1 Capsule By Mouth Once Daily – 8:00 Am -Diclofenac Sod Ec 75 Mg Tab Take 1 Tablet By Mouth Twice Daily – 8:00 Am, 5:00 Pm 3. A review of R1's medical record revealed no documentation of a signed medication order or verbal medication order for the above-mentioned medication. However, a review of the medication recap revealed the following active medications for R1: -Acetaminophen 325 mg Tablet (Tylenol 325 mg Tablet) Take 2 tablets by mouth every 4 hours as needed for pain or fever Start Date: 10/01/2024 – No End Date -Diclofenac 1% Gel – OTC Apply 2 grams topically to affected area(s) 4 times daily Start Date: 10/01/2024 – No End Date -Diclofenac Sod EC 75 mg Tab Take 1 tablet by mouth twice daily Start Dates: 10/01/2024 – No End Date -Nitrofurantoin Mono-Mcr 100 mg Take 1 capsule by mouth twice daily Start Dates: 09/10/2025 – No End Date -Sennoside S 8.6 mg–50 mg Take 2 tablets by mouth every evening as needed Start Dates: 10/01/2024 – No End Date -Tamsulosin HCl 0.4 mg Capsule Take 1 capsule by mouth once daily Start Dates: 05/04/2025 – No End Date 4. During an observation, the physical medications for R1 from Saliba's Pharmacy were observed to be available. 5. A review of R2's medical record revealed a current written service plan that included directed care services and medication administration. 6. A review of R2's medical record revealed an August 2025 and September 2025 eMAR. The eMAR included the following medication, which was administered to R2 from August 2025 to present; - Atorvastatin 40 mg tablet – Take 1 tablet by mouth at bedtime – 8:00 PM -Memantine HCL 5 mg tablet – Take 1 tablet by mouth every 12 hours for dementia – 8:00 AM, 8:00 PM -Acidophilus-Pectin Capsule (Acidophilus Capsule) – Take 1 capsule by mouth once daily – 8:00 AM -Eliquis 2.5 mg tablet – Take 1 tablet by mouth twice daily – 8:00 AM, 5:00 PM -Donepezil HCL 5 mg tablet – Take 1 tablet by mouth at bedtime – 8:00 PM -Fluoxetine HCL 20 mg cap – Take 1 capsule by mouth once daily in the morning – 8:00 AM -Bupropion HCL 75 mg tablet – Take 1 tablet by mo

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for two of two residents sampled. The deficient practice posed a risk if the resident experienced a change in condition due to improper administration of medication. Findings include: 1. A review of R1's medical record revealed a current service plan that included personal care services and medication administration. 2. A review of R1's medical record revealed an August 2025 and September 2025 electronic medication administration record (eMAR). The eMAR included the following medication, which was administered to R1 from August 2025 to present; -Diclofenac 1% Gel – Otc Apply 2 Grams Topically To Affected Area(S) 4 Times Daily – 8:00 Am, 12:00 Pm, 5:00 Pm, 8:00 Pm -Nitrofurantoin Mono-Mcr 100 Mg Take 1 Capsule By Mouth Twice Daily – 8:00 Am, 5:00 Pm -Tamsulosin Hcl 0.4 Mg Capsule Take 1 Capsule By Mouth Once Daily – 8:00 Am -Diclofenac Sod Ec 75 Mg Tab Take 1 Tablet By Mouth Twice Daily – 8:00 Am, 5:00 Pm 3. A review of R1's medical record revealed no documentation of a signed medication order or verbal medication order for the above-mentioned medication. However, a review of the medication recap revealed the following active medications for R1: -Diclofenac 1% Gel – OTC Apply 2 grams topically to affected area(s) 4 times daily Start Date: 10/01/2024 – No End Date -Diclofenac Sod EC 75 mg Tab Take 1 tablet by mouth twice daily Start Dates: 10/01/2024 – No End Date -Nitrofurantoin Mono-Mcr 100 mg Take 1 capsule by mouth twice daily Start Dates: 09/10/2025 – No End Date -Tamsulosin HCl 0.4 mg Capsule Take 1 capsule by mouth once daily Start Dates: 05/04/2025 – No End Date 4. During an observation, the physical medications for R1 from Saliba's Pharmacy were observed to be available. 5. A review of R2's medical record revealed a current service plan that included directed care services and medication administration. 6. A review of R2's medical record revealed an August 2025 and September 2025 eMAR. The eMAR included the following medication, which was administered to R2 from August 2025 to present; - Atorvastatin 40 mg tablet – Take 1 tablet by mouth at bedtime – 8:00 PM -Memantine HCL 5 mg tablet – Take 1 tablet by mouth every 12 hours for dementia – 8:00 AM, 8:00 PM -Acidophilus-Pectin Capsule (Acidophilus Capsule) – Take 1 capsule by mouth once daily – 8:00 AM -Eliquis 2.5 mg tablet – Take 1 tablet by mouth twice daily – 8:00 AM, 5:00 PM -Donepezil HCL 5 mg tablet – Take 1 tablet by mouth at bedtime – 8:00 PM -Fluoxetine HCL 20 mg cap – Take 1 capsule by mouth once daily in the morning – 8:00 AM -Bupropion HCL 75 mg tablet – Take 1 tablet by mouth once daily in the morning – 8:00 AM -Gabapentin 100 mg capsule – Take 1 capsule by mouth 3 times daily at 8:00 AM, 1:00 PM, and 8:00 PM – 8:00 AM, 1:00 PM, 8:00 PM -Bupropion HCL 100 mg tablet – Take 1 tablet by mouth once daily in the morning – 8:00 AM -Lisi

Based on record review, observation, and interview, the manager failed to ensure that a medication administered to a resident was accurately documented in the resident's medical record for two of two residents sampled. The deficient practice posed a risk as the medical record inaccurately indicated a medication was administered, and the Department was provided false or misleading information. Findings include: 1. A review of R1's medical record revealed a current written service plan that included personal care services and medication administration. 2. A review of R1's medical record revealed no documentation of a signed medication order for the medication below. However, a review of the medication recap revealed the following active medications for R1: -Diclofenac 1% Gel – OTC Apply 2 grams topically to affected area(s) 4 times daily Start Date: 10/01/2024 – No End Date -Diclofenac Sod EC 75 mg Tab Take 1 tablet by mouth twice daily Start Dates: 10/01/2024 – No End Date -Nitrofurantoin Mono-Mcr 100 mg Take 1 capsule by mouth twice daily Start Dates: 09/10/2025 – No End Date -Sennoside S 8.6 mg–50 mg Take 2 tablets by mouth every evening as needed Start Dates: 10/01/2024 – No End Date -Tamsulosin HCl 0.4 mg Capsule Take 1 capsule by mouth once daily Start Dates: 05/04/2025 – No End Date 3. A review of R1's medical record revealed an August 2025 electronic medication administration record (eMAR). The eMAR had not documented the following medications for August 2025 as administered: -Diclofenac 1% Gel – Otc Apply 2 Grams Topically To Affected Area(S) 4 Times Daily 8:00 AM – August 4th, 7th , 9th , 11th –17th , 19th –21st , 24th , 27th –29th , and 31st. 12:00 PM – August 1st – 31st. 5:00 PM – August 1st – 4th, 6th – 31st. 8:00 PM – August 1st – 31st. -Tamsulosin Hcl 0.4 Mg Capsule Take 1 Capsule By Mouth Once Daily 8:00 AM – August 26th 4. In an interview, E1 and E3 reported that the above-mentioned medications were administered; however, the administrations were not properly documented. 5. A review of R1's medical record revealed an August 2025 eMAR. The eMAR had documented the following medications for August 2025 as administered; -Nitrofurantoin Mono-Mcr 100 Mg – Take 1 capsule by mouth twice daily for 10 days – Times: 8:00 AM, 5:00 PM with a Start Date: 10/01/2024. However, this medication was prescribed for only 10 days and was administered on August 8th. During an observation of R1's medications, Nitrofurantoin Mono-MCR 100 mg was not observed. - Doxycycline Mono 100 Mg Cap Take 1 – Capsule By Mouth 2 Times A Day For 14 Days. Times: 8:00 Am, 5:00 Pm – Start Dates: 02/11/2025. However, this medication was prescribed for only 14 days and was administered on August 1st, 8th, and 26th. During an observation of R1's medications, Doxycycline Mono 100 Mg Cap was not observed. 6. In an interview, E1 reported that the above-mentioned medications had been discontinued and were not administered; however, they were documented in the eMAR as having been a

Based on documentation review and interview, the manager failed to ensure that a disaster drill for employees was conducted on each shift at least once every three months and documented. The deficient practice posed a risk if employees were unable to implement a disaster plan. Findings include: 1. A review of the facility's personnel schedule revealed there were two shifts: Day and Night. 2. A review of the facility's disaster drills revealed documentation of a disaster drill conducted on the following dates and times: -January 01, 2025 at 9:00 AM -January 01, 2025 at 6:00 PM -April 01, 2025, at 9:00 AM -April 01, 2025, at 6:00 PM However, no documentation was provided to demonstrate that a drill was conducted between April 2025 to present. 3. In an interview, E1 acknowledged that a disaster drill for employees was not conducted on each shift at least once every three months. 4. In an exit interview, the findings were reviewed with E1, and no additional information was provided. 5. This is a repeat deficiency from the compliance inspection conducted on May 18, 2022.

Violation cited

Violation cited

Violation cited

Violation cited

Violation cited

Based on observation, interview and documentation review, the manager failed to ensure oxygen containers were secured in an upright position. The deficient practice posed a potential explosion or leak of a compressed gas and the Department was provided false and misleading documentation. Findings include: 1. The Compliance Officer observed three oxygen containers stored upright in R1's bedroom closet. One oxygen container was on a two-wheel vertical medical cylinder cart, however, two oxygen containers were not secured. 2. In an interview, E1 acknowledged there were unsecured oxygen containers in R1's bedroom closet. E1 reported E1 had attempted to have the oxygen containers returned to the home health company but had been unsuccessful. E1 acknowledged E1 submitted a plan of correction to the Department, stating the oxygen containers had been secured and acknowledged this was false information. 3. A review of facility documentation revealed a Plan of Correction (POC) received by the Licensee on September 19, 2023. The POC stated "The Manager secured both oxygen containers that were located in a resident's bedroom and are now safely stored in and [sic] upright position and secured, away from flammables and open flames. The Manager retrained and instructed all facility personnel to check and ensure that all oxygen containers are secured in an upright position." 4. Based on photographic evidence, obtained on August 22, 2023 and December 4, 2023, the oxygen containers were not secured and were in the same location. 5. Based on photographic evidence, obtained on December 4, 2023, the oxygen containers were not secured as indicated in the aforementioned POC. 6. Based on photographic evidence, provided by E1 on December 4, 2023, E1 attempted to purchase an oxygen cylinder storage rack through an online marketplace (date unknown). However, E1 did not follow-through with the purchase, though the seller contacted E1 three additional times to see if E1 was still interested in the oxygen cylinder storage rack, on October 2, October 4 and October 6, 2023. This deficiency was found to be uncorrected from the compliance inspection conducted on August 22, 2023.

Based on documentation review, record review and interview, the health care institution failed to administer a training program for all staff regarding fall prevention and fall recovery. Findings include: 1. A review of facility documentation revealed a policy and procedure titled "Fall Prevention" updated October 1, 2022. The policy stated "Fall prevention and recovery training is required upon hire and at least every 12 months thereafter." 2. A review of E1's (hired in 2021) personnel record revealed training in fall prevention and fall recovery, dated January 10, 2022. However, subsequent documentation was not available for review. 3. A review of E2's (hired in 2021) personnel record revealed training in fall prevention and fall recovery, dated January 10, 2022. However, subsequent documentation was not available for review. 4. A review of E3's (hired in 2022) personnel record revealed training in fall prevention and fall recovery was not available for review. 5. In an interview, E1 acknowledged E1's and E2's fall prevention and fall recovery training documentation was not completed within the last 12 months. E1 reported E3 had been trained to the fall prevention training program but E1 was unable to locate E3's training documentation.

Based on documentation review, record review and interview, the manager failed to ensure documentation required by Article 8 was provided to the Department within two hours after a Department request. The deficient practice posed a risk as the Department was unable to determine substantial compliance. Findings include: 1. The Compliance Officer requested the following at 9:15 AM: -Employee disaster drills -Resident and employee evacuation drills -Disaster plan and annual review -Four personnel records -Two medical records -Policies and procedures manual -Fall prevention and fall recovery training program and documentation of personnel member's training 2. The Compliance Officer conducted the exit interview with E1 and E2 at 11:40 AM and the following documentation had not been provided to the Department for review: -Documentation of E3's fall prevention and fall recovery training 3. In an interview, E1 acknowledged the aforementioned documentation was not provided to the Department within two hours after a Department request. This is a repeat deficiency from the compliance inspection conducted on May 18, 2022.

Based on observation, documentation review, and interview, the manager failed to ensure there was a means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort to provide access to an outside area from which a resident may exit to a location at least 30 feet away from the facility, and controlled or alerts employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. The Compliance Officer observed three ambulatory residents on the premises. 2. The Compliance Officer observed the front door provided driveway and street access. The Compliance Officer observed a deadbolt on the front door. 3. The Compliance Officer observed the back door provided patio and back yard access. However, the Compliance Officer observed the door did not control or alert employees of the egress of a resident from the facility when the door was opened or closed. 4. A review of Department documentation revealed the facility was licensed to provide directed care services to residents. 5. In an interview, E1 and E2 acknowledged the back door did not control or alert employees of the egress of a resident from the facility when the door was opened or closed. E2 reported E2 was unaware of this requirement.

Based on observation and interview, the manager failed to ensure a food menu was conspicuously posted at least one calendar day before the first meal on the food menu was served. The deficient practice posed a risk if the source of a potential food borne illness could not be identified. Findings include: 1. The Compliance Officer observed a posted food menu for the week of August 1-5, 2023. 2. In an interview, E2 acknowledged the current food menu was not conspicuously posted. E2 then posted the current food menu on the wall. 3. In an interview, E1 reported the facility used a rotating food menu. The Compliance Officer showed E1 a photograph of the posted food menu dated from August 1-5, 2023. E1 acknowledged the facility had not updated the food menu in several weeks. This is a repeat deficiency from the compliance inspection conducted on May 18, 2022.

Based on documentation review and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months. Findings include: 1. A review of facility documentation revealed a disaster plan review completed on January 19, 2022. However, a completed review at least once every 12 months since January 19, 2022 was not available for review. 2. In an interview, E1 acknowledged a review of the disaster plan had not been completed at least once every 12 months.

Based on observation, interview and documentation review, the manager failed to ensure oxygen containers were secured in an upright position. The deficient practice posed a potential explosion or leak of a compressed gas. Findings include: 1. The Compliance Officer observed three oxygen containers stored upright in R1's bedroom closet. One oxygen container was on a two-wheel vertical medical cylinder cart, however, two oxygen containers were not secured. 2. In an interview, E1 acknowledged there were unsecured oxygen containers in R1's bedroom closet. E1 reported to be unaware the oxygen containers were required to be stored secured and in an upright position.